Treatment of Irritable Bowel Syndrome with Constipation (IBS-C)

First-Line Treatment: Lifestyle and Dietary Interventions

The American Gastroenterological Association recommends starting with soluble fiber (ispaghula or psyllium) at 3-4 g/day, increasing gradually to avoid bloating and gas 1
Regular physical exercise is recommended to all IBS-C patients as it improves global symptoms and forms the foundation of treatment 2
Patients should be advised to have regular meal patterns, adequate hydration (at least 8 cups of fluid daily), and limit caffeine, alcohol, and gas-producing foods 2
Avoid insoluble fiber (wheat bran) entirely as it consistently worsens IBS symptoms, particularly bloating 2

Linaclotide 290 mcg once daily is the most efficacious secretagogue available for IBS-C, with strong recommendation and high-quality evidence 1
The European Society of Gastroenterology recommends linaclotide as the preferred agent for second-line treatment of IBS-C 1
Lubiprostone 8 mcg twice daily with food is an effective alternative if linaclotide is not tolerated 1

The American College of Gastroenterology recommends tricyclic antidepressants (TCAs) as gut-brain neuromodulators for refractory pain in IBS-C patients 2
Start amitriptyline 10 mg once daily at bedtime, titrating slowly to 30-50 mg daily 2

IBS-specific cognitive behavioral therapy (CBT) is effective for global symptoms with strong recommendation 1
Gut-directed hypnotherapy is effective for global symptoms with strong recommendation 1

The British Dietetic Association recommends a low-FODMAP diet as second-line dietary therapy for IBS-C patients if symptoms persist after first-line fiber therapy 2
This must be supervised by a trained dietitian with planned reintroduction of foods according to tolerance 2